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802 Sparks Rd . j � '�� � � � � d �, � �'o'-,�"�� ' ' Davie County Environmental Health � ' �0 � , • '' P.O.Box 848/210 Hospital Street /� I � Mocksville,NC 27028 I(}I (336)753-6780/Fax(336)753-1680 WELL PERMIT �ccou�t #�: 990005474 . - T�X:P.1�€iEH#: 5853-54-5734-Well _ _ , . - BiElc�i To: Elizabeth Fenwick . ; SuE�divisiart�.in�f�:,,������ _ � . , Refer�r�ce Nar��e: , . ',.�,LocalioniAddress: 802 Sparks Road-27028;` Proposed Fa�iiity: Residential Well ="<, . . :> : � �;".. P�o�er#y�Size',1,���'16 acres ; , ; •: - - - , : K .._,,� �:--� �TC Numb�r: 0064 , . . ,-<� � _ . Actions of the employees of the Davie County EH Section shall in no way be taken as a guarantee that this well will produce water of any particular quantity or quality or for any amount of time. This permit is valid for a period of 5 years from the date of issuance. This permit may be revoked if it is determined that there has been a material change in any facticircumstances upon which this permit was issued. Permit Type: New [� Repair ❑ Abandonment ❑ Proposed Well Lo tion Diagram Certificate of Completio,�Diagram � ., ..� . / J � � / I I , i � / J ' _ � � �� � ��r ' . I � ' b� � / �_•a2 , �� , + ''J :' � T�J � . � � � � , Comments: � Driller: 1�IQ Q . Certification#: Grout Inspected: (� � Z�/� - Well Head Inspected: � 2 Q GPS Coordinates: a 2. � Q �.ZO� EHS:, Date: (� EHS: Date: W.P.7-08 Od 04 10 09:29a Ir�formation Seroices 3367531680 p.1 _ ��► . . � , , . .. . > ,;, , ' - �'_`� . D � c� � o ��--� � APP� TION FOR P�2IVATE WELL PERMIT '; _ 6 2010 vie County Environmental Heaith ��� P.O.Box 848/Z10 Hospltal Street Mocksville,NC 27028 �`N�����j�EGG�I� LjH 336)753-6780!Fax(336)753-I680 • ***IMPORT.4NT'k'�* THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF TF�REQUIRED II�TFORMAT[ON IS PROVIDED. APPLICANT INFOItMATION Name 1 ct.�j "- t.tJ(, � Contact Person 9'c9'zc��a Address d S�f— r Home Phone � City/State/ZiP 1 .� cS /b� Business Phone ' Name on Permit ifDif`'eren:than Above � Mailing Address CitylState/Zip PROPERTY INFORMATION _ *Date HouseJFaciIity Corncrs Flagged NOTE: A survey lat o7 site�la�n.��'ust a mpazry this application. Included: ❑Site Plan �Plat(to scale) ` Owner's Name�����:�-�� �.a.r..c�c� Phone Number "I� {-j z�3 ' Owner's Address City/State/Zip Property Address �3 D 2, ,��, eQ� City 2 ' Lot Siae � � o�cic� Tax PTN# c�Z 1 j��-�'�jl.�-57J�� Subdivision Name(if applicable) S tion/Lo Directions To Site: DEVELOPMENT INFORMATION Permit Type: New Well Well Repair Well tlbandonment Other(specify) Facility Type: Residential � Food Service Church Commercial Other Are There Any Septic Systems G�rrently On The Site? YES NO � Do You Intend To Install A New Se tic System On This Site? YES � NO TERMS AND CONDTTIONS: This application must be accompanied by a plat or site plan of the property that includes the existing and proposed pmperty(ines �vith dimensions,the specif c location of the facility and any existing or future appurtenances,the location of any existing septic system,sewer lines,water lines,any existing water supplies and any surface waters. The agplicant is responsible for identif}+ing nnd marking the property lincs and comers. 'Che applicant is zesponsible for making the site accessible. By signi.ng this application,the applicant signifies that they understand the terms and conditions and that they give permission for Davie County Environmental EIealth representatives to perform necessary field evaluafions and procedures deemed necessary to determine the best locadon for a weil. �� I� llv Signe Date Site Revisit Charge Date(s): ClientNotification Date: EHS: 7/30/09 Account#� �W///T ' f."_"_:__ L . \% 1 � WA'�ER SAMPLE�SEWAGE SYSTEM CHECK RE�UEST Date Requested: 25� 71 I DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION Received By -� , WATER SAMPLE TYPE: �8acterial O Protected C4� Chemical O Unprotected O Dug � � 9, Other: O Bored O Drilled �'Outside Spigot:y���/`t0145L O Other: ��..����.���.���.���.������.���.�.��.��������..���� SEWAGE SYSTEM CHECK: O Yes Vacant: O Yes O Approved / � O No O Disapproved Owner's Name: �IL� .�i`1 r6N i � Buyer's Name Property Address: Directions: �l 0 O ! � �/" Speciallnstructions: � S Letter To: Closing Da e: Attn: ----------- -------- � Date Taken: ! � Charges: Telephone: � � By: i��� Z y . - � �. � 2�� DAV1E COUNTY ENVIRONMENTAL HEALTH Z 2 P.O.Box 848/210 Hospital Str�e,t — - ZZ Mocksville,NC 27028 (336)753-6780/Fax#(336)753-1680 . , OPERATION PERMIT t, • �ccr�ur�t �: 990005474 Tax P1t�:EH#; 5853545734 Biflc�Ya: Elizabeth Fenwick Suf�divisiati Infc�: RefereE�ce N�r��e:: Gary Boggs LocationiAddr�ss: Sparks Road- Propc��ge! F�aci(ity: residence P�op�r�ty Size: 16 acres " . ATC Nut�ber: 5083 � **NOTE**The issuance ofthis Operation Permit shall indicate the system described on the ATC has been installed in compliance with Article 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. System Type: 8 S.T.Manufacturer_�'4C,�"� Tank Date�� Tank Size /G�O Pump Tank Size� � _ !a/z y . ��`� � �l� Z�lb System Installed By: �/(�`�./Y! {�/Q,� E.H.Specialis • Date: . G`��� �s� � -- . � . �s�,���. �� ,, . �,►� �, � ;�_� , -,, �._ . , , � - ' ` `� `� � �. (2�/'� . ��°�� ' � ���, �y � /, i ���' ��� � ; . � .,,�_ �� . DCHD 11/06(Revised) ' i . DAVIE COUNTY ENVIRONMENTAL HEALTH ": "' ' P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax#(336)753-1680 _. AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION � �cct�u�t #�: 990005474 "��x PI�€.�EH#: 5853545734 � Billc� To: Elizabeth Fenwick Sub�ivi4ior� lnf�: Re�ferwr�ce P�a��e: Gary Boggs l.ocatioNAddr�ss: Sparks Road- f�rop�3s�;c9 F��:iEity: residence �cn�zr#y S�iz�: 16 acres � t�TC N��'3b�3': 5083 Site Type: ❑N2w ❑Repair ❑Expansion **NOTE**This Authorization to Gonstruct(ATC)MUST BE ISSUED by the Davie Courity Environmental Health Section prior to issuance of any building permit(s),(in compliance with Article 11 of G.S.Chapter 130A Wastewater Systems,Section.1900 Sewage Treatment arid Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VAL-ID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat or the intended use change. Residential Specifications: #Bedrooms2_#Bathrooms #People Basement❑ Basement plumbing0 Non-Residential Specifications: Facility Type � #People #Seats Squaze Footage(or I�imensions of Facility) Lot Size�_ Type of Water Supply: ❑County/City ❑Well ❑Community Well System$pecifications: Design Wastewater Flow(GPD)�uv Tank Size b6UGAL.Pumn�,�,�G�AL. Trench Width 3� Max.Trench Depth�� Rock Dept';�Z,,:,'�,Linear Ft.� �o d � Site Modifications/Conditions/Other: � �� Z�%OI/�4(�u� Contact the Davie County Environmental Health Section for final i�s' ::an of this system between 8:30-9:30a.m.on the da of installation. Tele hr_`.';-: ,�36 751-8760. " -� �►uk. 6Wne� �'ar �-�, p�►�er10��a►�. ; � �� _ . � . �+�E � - _ 2� / ,'- _,, , s ���� , � e � �` , �3�6� , `��,'> � . Cz�.� �-- r�,� ,� . .�k4(p�' � ��. l , -v „� � �� ` �; o � "� . � `�� � ` ` �Q � � � : ; � � � � .. ' � Environmental Health Specialist Date: ���� DCHD 11/06(Revised) . • � Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 IMPROVEMENT PERMIT / Account #: 990005474 Tax PIN/EH#: 5853545734 Billed To: Elizabeth Fenwick Subdivision Info: Address: 2126 Forest Drive Location/Address: Sparks Road- City: Winston-Salem Property Size: 16 acres Reference Name: Gary Boggs Proposed Facility: residence **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is subject to revocation if site plans,plat or the intended use change. . Permit Type: �New ❑Repair �Expansion Permit Valid for: ,�5 Years ❑No Expiration Residential Specifications: #Bedrooms�#Bathrooms #People Basement❑ Basement plumbing❑ Non-Residential Specifications:.Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD):��v Type of Water Supply: ❑County/City �.Well ❑Community Well ��- c�.,— � Site Modifications/Permit Conditions: ,/�C'.1'1 � Q�. �l9� S stem T e LTAR Initial an • Z Re air C� .� Site Plan t�-� a�p� . �' ; . , _, ,. � - . � � � . � ,� 7 , ��� , � ( � c �, ���� �� 1 ' \ i� `�,` ��_ � , Environmental Health Specialist Date(�J_ (� -�1- i.p.11-06 / ` / ��'� 0, �c �,-'S► �L � � � Q��'�w���' QI`a -yo9 � Q�ay Q o� . _ l���,� � / ��.�1. �^�`ti�' �0� �'�i `'�` ��-���' $°2 ��.� / ��Q�y��Q� NIP A NEW� �� � �„�j.� � CORNER �'F +� � ,�tio�� � .�v� ��� � w �� �� , . � � � ` Q "�Mh � � � ���tA- J /�,x wire X fone� .. � � ��Y o'�'� � � �9 � ^�'� / " � / � ' NIP A NEW� � ' I� CO�� � 0 I ��. � / `.`_ ' s �. .d. ' �w / ' { i''� i '`•�' oeac � � C � ' ��. e��. e.mc o � �, M �� STONE � y J� � � ��:ai Fd. �i W E ��t � � I ` /�•. o i - �� � aro�.1 drM J °ona��/ 1 � �, ,�/ � , ��, o � ;,' � , I ' ' 11 Z I ' �PP . j �� ` � � 1 , �i' � ��� � r NIP A NEW � '�� I�! CORNER � ,r/`'��,�' � � � ✓ � �B.! � � � " I � � , � � �� �� i � � � � ' ��� y j. •� I i � 2.5�� � �ovp�y�� ��q . ��,,_: � ��� �� 1 ! PtPE 1 - ` - -�=sE� 3�f�` �� ' ����' i i . .-�� � � �—%' •' ' •� � NIP A NEW � � ` REh1NNING PROP�RT1(0�.. CORNER 1 1 ( \ ELIZABETH L. FE?`�'i�YIC l � , , � 1 \ DEEt� BOOK 83. PA�E'��,� ! I � i ,n (PRESEh(TLY T�;f P.ARCEL 23 ON TAX l.IAP 86) � / i � \� 1 YV r l t�r � � I 1 �� �, i �. , i � � �'P a .��/ 4�-- �N � i., ,� � �f � � oo ^ ,� ro� o 1 � � � � �z� 3 ��s �^ � ,a, � � � o N � i � ,� Z � � --� N�'/RON I I NER OFCE ~ ~_ •S 8��•���02.72• �NEW Cp�P�uNE � " I S PR�PER'fY '"• � J I � 70K 83 AT ~� �`. � � �F „Mnc.niat.-sEr �N°h,� S _wof� J l ��` PAVEMENT C,/L 1PfTERSECTION � S,�A rj rr�' 7 455 ?�� OF BOTH ROADS '�- 1� j1 j��`� - S 89•45'S9"E 308 • � \ �Iruc���i-Lua.:7� ' ~~O�"'� i 'd S88Z 866 9EE eZS �TO EO ZZ �dki � ' Davie County Environmental Health . . P.O.Box 848/210 Hospital Stre�t — , Mocksville,NC 27028 � � (336)753-6780/Fax(336)753-1680 IMPROVEMENT PERMIT � �, Account #: 990005474 Tax PIN/EH#: 5853545734 Billed To: Elizabeth Fenwick Subdivision Info: Address: 2126 Forest Drive Location/Address: Sparks Road- City: Winston-Salem w Property Size: 16 acres �� Reference Name: Gary Boggs Proposed Facility: residence **NOTE**This Improvement Permit DOES NOT authorize the constructicjri of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to , revocation if site plans,plat or the intended use change. _.__._�_.__.____ �.____._ .____..____..._.�_�_.._.Y._..._.....------�.._....._.._.�_ ___..,_.__.__.._....__..___ ........_... __.._....... ..._.. Permit Type:. New ❑Repair OExpansion Permit Valid for: PI5 Years ONo Expiration Residential Specifications: #Bedrooms 2 #Bathrooms #People Basement❑ Basement plumbing0 Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) � Design Flow(GPD):�� Type of Water Supply: ❑County/City ❑Well �ommunity Well Site Modifications/Permit Conditions: S stem T e LTAR Initial oH Re air `" / Site Plan 1 �� r • • � ,.. b- � . ( � � �� � � � . � ��`' ,� � -- ��'` . � -$ � � _ , � \ f I � � ��� � �, , �. iI Environmental Health Specialist � Date 2 i.p.l 1-06 � , - � R SITE EVALUATION/IMPROVEMENT PERMIT & ATC � � Davie County Environmental Health P.O.Box 848/210 Hospital Street � O � '� �-��� Mocksville,NC 27028 PQR 1 � (336)753-6780/Fax(336)753-1680 EA pplic tio • ��;� ion/Improvement Permit �Authorization To Construct(ATC) ❑ Bot _ T e o Ap at�6 ew System ❑Repair to Existing System ❑Expansion/Modification of Existing y em or Facility *� PORTANT***THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED: Refer to the INFORMATION BULLETIN for instructions. � APPLICANT INFORMATION � � � Name 1 '�� l � �ontact Person Crc�t� ` Add'ress ��}-� Home Phone Q q 8 -- 1�„�6 � City/State/ZIP �. B Business Phone 5 a�wt� `�o� 2� b Name on PerrnitlATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facilit Corners Fla ed � NOTE: A survey plat or site plan must accompany this application. Included: €�'S�ite Plan �Plat(to scale) � (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name �l,��QD Phone Number Owner's Address 1 c�, l� � � City/State/Zip� �����y� .. �)��'/� Property Address`� .s S City Lot Size /��-�,�..a� Tax PI # S'�S�S yS"� ��1 Subdivision Name(if applicable) Section/Lot# Directions To Site: If the answer to any of the following questions is"Yes",supporting documentation must be attached: Are there any existing wastewater systems on the site?. _Yes �R10 � ,. Does the site contain jurisdictional wetlands? . Yes vPd� Are there any easements or right-of-ways on the site? Yes `iQo Is the site subject to approval by another public agency? Yes v�o � Will wastewater other than domestic sewage be generated? Yes� IF RESIDENCE FILL OUT THE BOX BELOW��,� �u-� #People ( #Bedrooms Z #Bathr�o ms � Garden Tub/Whirlpool ❑Yes o Basement: OYes � Basement Plumbing: ❑Yes �3Qo IF NON-RESIDENCE FILL OUT THE BOX BELOW � Type of FacilityBusiness Total Square Footage of Building #People #Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats � Type system requested: Conventional ❑Accepted ❑Innovative ❑Altemative �.Other Water Supply Type: ❑ County/City Water 0 New Well C9'Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes �'1Qo If yes,what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permit(s)or ATC(s)issued hereafter are subject to suspension or revocation.if the site is altered,the intended use changes,or if the information submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized Renresentative of the Da��ie Coimty Health Department to conduct ne�:essary incpections to deterr::ine compliance�vitli applicable ' laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging or staking the house/fa ility location,proposed well location and the location of any other amenities. Site Revisit Charge Prope owner's or owncr's legal representative signature �, �_ ,_ �� � Date(s): /.� J/ (� �Y�T�� ClientNotification Date: Date �y�, J��� ��� (�.�..p EHS: �" -(�-�� ) `� .�5'�� �K�s�;ng w� � o�� Q �1p`�n ��US('i Sign given CYes ❑No Account# � Revised 11/06 Invoice# ��,! .S�r oQ`v � Q,�',�Q'� QI"' "�" '� � , , . / ��. ,��Q o� `��'��� ,%// �����,�G��, �o�,�p/�,�t0��a � � � '�o � 5 % � �Q NIP A NENI �,.0� CORNER � �� �� / ��,O(���, 0���/ � ��C'��,- Q�"��1�•� ,� 1 V / �0,�, / � � +- J /�X wire . x tance � � �c�,°��^��� � o g / "'��/ " / NIP A NEW� � ' � CORNER �- m / -•'_". � �_...�'� i 3 . . . . . � ' st°pa � . / M i �e� DECK wood wal: / � O � build , M I eona Drick w�bcamt ^ ' � 1 c� �ahelt aONE a W �� _" a�,. a ` ��stcii' r �i I ` ` N E . o�, � �O - - � � � 4 �planter ls I . . � . • . . _ � I � I� �ravel ddve � aroa /. / \ � � / . '� �� � �. I I�� ' � / / . t�ti � � � , � . o , , • � . . { I � z ��PP �.�, �_� � � � � .h -`,� �_ , , � � o NIP A NEW ��" `-` / g I�I � CORNER � I �-� \ f ��� � : � ' � � I � s% �' � �' � � � �F� ' . P�- ` j ��c V� � � � � r- o � �,/ 2 > ' � 2.5" OLD IROt ��ERh}� �F' � �\ �� I I PIPE Fd.AT f ��R�SE= o.�EgN/ r �, � I I FENCE COR. 1 �� J `�= l � ' \ RE M I U N I N G P R O P E R T Y O F �' ; NIP A NEIN . � � � ELIZABETH L. FENWICK � CORNER , , � i t � ' pEED 80�K 83, �PAGE 421 / i � � 'n (PRESENTLY TA;t PARCEL 22 ON TAX MAP 86) I � � T �� / I 1 Q ' `f' . Lt! � � N; ",�' � � ei' I I � '�� �� \ � N I m l � ,� > a�• a p 1� � �. � �- . � �a� o �. �, �'�s� ° Z � �- � �-i 3 � � � � �'o N i�► I c�/ � � I1 � w � � � � " 3 ~ �' �. s o rnf UNk� �� OLD PRO rPE S� I I A o Y 81'O l"1502.7z• �a N�'�oRN�j R�UNE I � � `�'• I I �.. _~ � .�-�• � ��' R'OF "MAG NAIL SET IN TFiE S.R, K'D�� I I �F�� N 78' . PAVE}�ENT C,!L INTERSEC110N SP q�� �45S a OF BOTH ROADS � �-- ` n �. RE6W �e u9°45�59��E 30`. _' �--��,O�ri.D .�"n \ �FROM�. N�j�qw�ORNER pF jF.le� `" �,. )lNE, DO CERTIFY THAT THIS PLAT WAS f11A�(`T/lAI AAIn cllDcc�nc�n�,� cnn�i .0 � � ' � . �+� _ • �. ' • . DAVIE COUNTY HEALTH DEPARTMENT - ' Environmental Health Section Soil/Site Evaluation � APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990005474 , Tax PIN/EH#: 5853545734 °� Billed To: Elizabeth Fenwick Subdivision Infa Reference Name: Gary Boggs � Location/Address: Sparks Road- ^5-/_ / Proposed Facility: residence Propecty Size: 16 acres Date Evaluated: ��l GK. � �/�ylz�co -�(�-Z Water Supply: • On-Site Well ✓ Community Public Evaluation By: Auger Boring V Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e position • SlOpe % ' b 0 nv �'c � HORIZON I DEPTH � O— p—�l ^ O Texture rou . L ` � - Consistence L (/� Structure :r �� � Mineralo HORIZON II DEPTH � �� � _� L - O Texture rou • � (, C Consistence ' Structure Mineralo -aCQ HORIZON III DEPTH - -�( v Texture rou CL., C L Consistence ' % Structure ' � A� (' Mineralo � " ' HORIZON IV DEPTH Texture rou Consistence Structure � Mineralo , SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION � LONG-TERM ACCEPTANCE RATE . , .2, + ` r SITE CLASSIFICATION: �J � 1 EVAL �Y: L 'C LONG-TERM ACCEPTANCE RATE: •� OTHER(S)PRESENT: � ' ,� �c� REMARKS: O�1 .(. � LEGEND I,�n�caoe Position R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope Texture . S-Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CON4I4T+.N . � Msis� VFR-Very friable FR-Friable FI-Firm VFT-Very firm EFI-Extremely fum � � NS-Non sticky SS-Slightly sticky S-Sticky _ VS -Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic s Structure , SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogv 1:1,2:1,Mixed Notes Horizon depth-In inches Depth of fill-In inches . . 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